Evaluation of flash glucose monitoring after long-term use: A pediatric survey

Prevalence of dermatitis including allergic contact dermatitis from medical devices used by children and adults with Type 1 diabetes mellitus: A systematic review and questionnaire study

Use of medical devices (MDs), that is, glucose sensors and insulin pumps, in patients with Type 1 diabetes mellitus (T1D) has proven an enormous advantage for disease control. Adverse skin reactions from these MDs may however hamper compliance. The objective of this study was to systematically review and analyse studies assessing the prevalence and incidence of dermatitis, including allergic contact dermatitis (ACD) related to MDs used in patients with T1D and to compare referral routes and the clinical investigation routines between clinics being part of the European Environmental and Contact Dermatitis Research Group (EECDRG). A systematic search of PubMed, EMBASE, CINAHL and Cochrane databases of full-text studies reporting incidence and prevalence of dermatitis in persons with T1D using MDs was conducted until December 2021. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at EECRDG clinics focused on referral routes, patient numbers and the diagnostic process. Among the 3145 screened abstracts, 39 studies fulfilled the inclusion criteria. Sixteen studies included data on children only, 14 studies were on adults and nine studies reported data on both children and adults. Participants were exposed to a broad range of devices. Skin reactions were rarely specified. It was found that both the diagnostic process and referral routes differ in different centres. Further data on the prevalence of skin reactions related to MDs in individuals with T1D is needed and particularly studies where the skin reactions are correctly diagnosed. A correct diagnosis is delayed or hampered by the fact that, at present, the actual substances within the MDs are not declared, are changed without notice and the commercially available test materials are not adequately updated. Within Europe, routines for referral should be made more standardized to improve the diagnostic procedure when investigating patients with possible ACD from MDs.

Impact of continuous glucose monitoring on everyday life of young children with type 1 diabetes and their parents: An evaluation of 114 families

INTRODUCTION

The prevalence of type 1 diabetes is increasing worldwide. The advent of new monitoring devices has enabled tighter glycemic control.

AIM

To study the impact of glucose monitoring devices on the everyday life of young children with type 1 diabetes (T1D) and their parents.

METHODS

A questionnaire was addressed to parents of children with T1D under the age of 6 years with an insulin pump treated in one of the hospitals of the ADIM network in France between January and July 2020.

RESULTS

Among the 114 families included in the study, 53% of parents (26/49) woke up every night to monitor blood glucose levels when their child had flash glucose monitoring (FGM), compared with 23% (13/56) of those whose child had continuous glucose monitoring (CGM). Overall, 81% of parents (86/108) found that glucose monitoring improved their own sleep and parents whose child had CGM were significantly more likely to report improved sleep (86% vs 73%, p = 0.006). Forty-nine percent of parents (55/113) declared that they (in 87% of cases, the mother only) had reduced their working hours or stopped working following their child's T1D diagnosis. Maternal unemployment was significantly associated with the presence of siblings (p = 0.001) but not with glycemic control (p = 0,87). Ninety-eight percent of parents (105/107) think that glucose monitoring improves school integration.

CONCLUSION

In these families of children with T1D, new diabetes technologies reduced the burden of care but sleep disruption remained common. Social needs evaluation, particularly of mothers, is important at initial diagnosis of T1D in children.

High incidence of skin reactions secondary to the use of adhesives in glucose sensors or insulin pumps for the treatment of children with type 1 diabetes

AIMS

To evaluate the incidence of the skin reactions secondary to continuous subcutaneous insulin infusion (CSII) or continuous glucose monitoring (CGM), sensors and the characteristics of affected children with type 1 diabetes.

METHODS

An observational, retrospective, single-centre study included 198 children with type 1 diabetes, (46% girls, mean age 11.75 years). A standardised questionnaire was completed with the patient during current care to evaluate the skin reactions (mean and percentage), the type of reaction, their impact and the treatment) and the characteristics of affected children with univariate and multivariate analysis.

RESULTS

Sixty-seven children (33.8%) reported active skin reactions: 45 children with CSII (30.4%) and 46 with CGM (23.5%). Children with skin reactions were younger (mean age 10.6 yo versus 12.34 yo, p < 0.05), with a younger age at the diagnosis of diabetes (5.59 yo versus 7.08 yo, p < 0.05). Atopy was more frequent in the group with skin reactions (76.1% versus 54.1% p < 0.05). On multivariate analysis, only the personal history of atopy was associated with skin reactions: OR 2.56 [1.16-5.97] (p < 0.05).

CONCLUSION

This study confirms the high incidence of skin reactions to adhesive devices used in the treatment of type 1 diabetes in children.

Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

BACKGROUND

Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association.

CONTENT

Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed.

SUMMARY

The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.

Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

BACKGROUND

Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association of Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association.

CONTENT

Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (Hb A1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of Hb A1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed.

SUMMARY

The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.

Flash glucose monitoring in young people with type 1 diabetes-a qualitative study of young people, parents and health professionals: 'It makes life much easier'

OBJECTIVES

Flash glucose monitoring for patients with T1 diabetes avoids frequent painful finger-prick testing, thus potentially improving frequency of glucose self-monitoring. Our study aimed to explore experiences of young people using Freestyle Libre sensors and their parents, and to identify benefits and challenges to National Health Service (NHS) staff of its adoption in their care provision.

PARTICIPANTS

Young people with T1 diabetes, their parents and healthcare professionals were interviewed between February and December 2021. Participants were recruited via social media and through NHS diabetes clinic staff.

DESIGN

Semistructured interviews were conducted online and analysed using thematic methods. Staff themes were mapped onto normalisation process theory (NPT) constructs.

RESULTS

Thirty-four participants were interviewed: 10 young people, 14 parents and 10 healthcare professionals. Young people reported that life was much easier since changing to flash glucose monitoring, increasing confidence and independence to manage their condition. Parents' quality of life improved and they appreciated access to real-time data. Using the NPT concepts to understand how technology was integrated into routine care proved useful; health professionals were very enthusiastic about flash glucose monitoring and coped with the extra data load to facilitate more tailored patient support within and between clinic visits.

CONCLUSION

This technology empowers young people and their parents to understand their diabetes adherence more completely; to feel more confident about adjusting their own care between clinic appointments; and provides an improved interactive experience in clinic. Healthcare teams appear committed to delivering improving technologies, acknowledging the challenge for them to assimilate new information required to provide expert advice.

Practicalities of Flash-monitoring systems utilization in the questionnaire survey of children and adolescents with type 1 diabetes mellitus

BACKGROUND: Children and adolescents with type 1 diabetes mellitus (T1DM) are recommended to perform self-control 6–10 times a day to maintain optimal blood glucose levels. Currently, there are various devices, such as glucometers, systems for continuous blood glucose monitoring and flash monitoring (FMS). In real clinical practice patients can combine the use of various devices and face with problems of their exploitation.

AIM: To investigate the peculiarities of FMS utilization by children and adolescents with T1DM using questionnaire survey.

MATERIALS AND METHODS: From 06.2020 till 05.2021, a survey of patients with T1DM was conducted as part of a single-center, observational, one-stage, uncontrolled study. The questionnaire contained questions regarding the number of measurements, circumstances and adverse reactions when using the devices.

RESULTS: We questioned 80 patients (47 girls and 33 boys) aged 11.7 (9.0; 14.0) years with DM1 for 4.9 (2.0; 7.0) years, HbA1c level 8.2 (6.8; 9.0)) which were in pediatric endocrinology department of the University Children’s Clinical Hospital.

The majority of patients (86.3%) scan the sensor more than 10 times a day; 25% of FMS-users measure blood glucose with glucometer not every day.

The majority of patients (51,3%) prefer to use FMS instead of glucometer in all circumstances. Patients face with errors using FMS more often than using glucometers — OR 3.4 (95% CI 1.7–6.8). Non-significant reaction to adhesive material disturbed 50.0% participants; one patient (1.3%) had to refuse FMS due to allergic reaction.

Among possible reasons to refuse FMS patients often name error, skin sealing, high price, inflammation, inconvenience to wear a device.

Additional measures for fixing FMS device are always used by 36,3% of patients, sometimes — 18,8%, in some situations (going in for sports, swimming, travelling, in case of unsticking at the end of term) — 15,0%.

CONCLUSION: Quarter of FMS users double-check glycaemia values rarer than recommended. Patients face with error using FMS more often than using glucometer. Local reaction to adhesive material does not influence FMS utilization. The majority of patients use additional measures for fixing FMS devices.

Flash glucose monitoring system in patients with type 1 diabetes in healthcare center in Brazil: real world data from a short-term prospective study

Objective

To evaluate the alternate use of flash glucose monitoring (FGM) with self-monitoring blood glucose (SMBG), in patients with type 1 diabetes (T1D).

Materials and methods

Two weeks of open FGM (P2), both preceded (P1) and followed by 2 weeks (P3) of SMBG with a blinded FGM system. Mean absolute relative difference (MARD) was calculated by (|FGMi - SMBGi|) / SMBGi, where it was a paired data sample.

Results

In total, 34 patients were evaluated. Time in range (TIR) did not change between P1 and P2. In 12 patients (35.3%), TIR increased from 40% at P1 to 52% at P2 (p = 0.002) and in 22 (64.7%), TIR decreased or did not change. FGM use resulted in decreased % time spent in hypoglycemia (<70 mg/dL) (6.5% vs. 5.0%; p = 0.005), increased % time spent in hyperglycemia (>180 mg/dL) (44.5% to 51%; p = 0.046) with no significant change in % TIR. The proportion of patients who reached sensor-estimated glycated hemoglobin (eA1c) < 7% decreased from 23.5% at P1 to 12.9% at P2, p = 0.028. For the whole sample, the MARD between the two methods was 15.5% (95% CI 14.5-16.6%). For normal glucose range, hyperglycemic levels and hypoglycemic levels MARD were 16.0% (95% CI 15.0-17.0%), 13.3% (95% CI 11.5-15.2%) and 23.4% [95% CI 20.5-26.3%)], respectively.

Conclusion

FGM after usual SMBG decreased the % time spent in hypoglycemia concomitant with an undesired increase in % time spent in hyperglycemia. Lower accuracy of FGM regarding hypoglycemia levels could result in overcorrection of hypoglycemia.

Flash Glucose Monitoring System facilitates sustainable improvements in glycemic control in patients with type 1 diabetes: A 12-month follow-up study in real life

BACKGROUND AND AIMS

Examine the glycemic control on Type 1 Diabetes (T1D) wearing the Flash Glucose Monitoring (FGM) system for a one-year period of time.

METHODS

This prospective study done using 187 patients with T1D (14-40yrs) who self-tested their glucose levels by FGM. Continuous glucose monitoring (CGM) metrics were gathered i.e., Glucose Variability (GV) (%), mean Time in Range (TIR), Time Above Range (TAR), Time Below Range (TBR), and average duration of hypoglycemic events at the 3, 6, and 12 month time periods.

RESULTS

At 6th, 9th and 12th months, for values of GV, % in target, TAR and %>250 mg/dL, no significant changes (p > 0.05) were noted compared to 3 months. However, significant changes from the baseline were evident for the values of the mean glucose level at the 3rd (p = 0.028), 9th (p = 0.048) and 12th months (p = 0.022). When the mean glucose value at 3 months was compared to the same at 6, 9, and 12 month period, no significant changes (p > 0.05) were seen. When compared with baseline values, low glucose events at 3 months (p = 0.028), 6 months (p = 0.048), 9 months (p = 0.022) and 12 months (p = 0.038) showed significant changes. However, the percentage below 70 mg/dL (barring the value at 12 months, p = 0.046), no significant changes were observed. The HbA1c revealed significant drop in 3, 6, 9 and 12 months compared to baseline values.

CONCLUSION

Significant improvement was noted in CGM metrics when patients switched from conventional finger pricking method over to FGM system, and the effect was observed during the entire study period.

Evaluation of the performance and usability of a novel continuous glucose monitoring system

Background

Continuous glucose monitoring (CGM) can help manage diabetes mellitus (DM) and prevent hypoglycemia. This study aimed to evaluate the performance and usability of a novel SiJoy GS1 CGM system.

Methods

This multicenter trial enrolled participants with DM. Based on the comparison of glucose values measured by SiJoy GS1 CGM and venous blood glucose test, the 20/20% consistency and mean absolute relative difference (MARD%) were calculated, as well as Clarke and consensus error grid analysis. Product usability was evaluated by questionnaire completed by participants. Any occurrence of adverse events (AE) was documented.

Results

Seventy participants were included in the study. The mean age of participants was 41.5 ± 13.2 years, among which 29 (42.0%) were male, with the DM course of 8.6 ± 7.5 years. A total of 39 (56.5%) of them had type 1 DM, 24 (34.8%) had type 2 DM, and 6 (8.7%) were others for DM. The 20/20% consistency achieved 91.82%, which was higher than the target 65%. The percentage of A + B zones of Clarke and consensus error grid was 99.22% and 99.90%, respectively. The MARD value was 8.83% ± 4.03%. The mean score of usability questionnaire was 86.59 ± 5.17 out of 90. AE were observed in only one participant (mild fever), and no severe AEs occurred.

Conclusions

The SiJoy GS1 CGM system achieved satisfactory performance and usability. No severe AEs occurred and mild AE was reported in only one case.

[Evaluation of FreeStyle Libre in pediatric t1dm: improved glycemic control, reduction in diabetic ketoacidosis and severe hypoglycemia]

BACKGROUND

Self-monitoring of blood glucose (SMBG) with glucometers provides only a snapshot of the glycemic profile and is accompanied by significant psychological discomfort and pain, especially in children. Flash Glucose Monitoring System - FreeStyle Libre (FSL) overcomes many of the barriers associated with glucose measurement and improves metabolic control.

AIM

To evaluate the efficacy of FSL in children with type 1 diabetes mellitus (T1DM) in terms of glycemic control, episodes of severe hypoglycemia (SH) and diabetic ketoacidosis (DKA).

MATERIALS AND METHODS

A multicenter, prospective, observational study in real clinical practice was carried out. A total of 469 subjects (258 boys and 211 girls) aged 4-18 were included in the study. The median age was 11.3 (8.4-14.6) years, duration of T1DM - 4.2 (2.1-7.1) years. After FSL start, patient was followed up for 6 months.

RESULTS

After 3 and 6 months of FSL use, HbA1c significantly decreased from 7.4% to 7.1% and 7.2%, respectively (p&lt;0.001). The number of children with HbA1c &gt;&lt;7.5% increased from 51% to 60% and 58% at 3 and 6 months, respectively (p&gt;&lt;0.001). The incidence of DKA and SH, as well as the proportion of patients experiencing at least one episode of DKA and SH, were significantly reduced after 6 months of FSL use compared with baseline (p&gt;&lt;0.001).

CONCLUSION

The Study demonstrated a significant improvement in metabolic control in children with T1DM 6 months after FSL start: decrease in HbA1c, accompanied by reduction in incidence of DKA and SH.

Effectiveness of the freestyle libre 2 flash glucose monitoring system on diabetes-self-management practices and glycemic parameters among patients with type 1 diabetes using insulin pump

AIMS

To determine the effectiveness of Freestyle Libre 2 (FSL2) on diabetes-self-management (DSM) practices and glycemic parameters among patients with type 1 diabetes (T1D) using insulin pump.

METHODS

This prospective study was performed among 47 patients with T1D (13-21yrs) who self-tested their glucose levels by the conventional finger-prick method using blood glucose meters (BGM). Data related to glycemic profile i.e., mean time in range (TIR), mean time above range (TAR) mean time below range (TBR), mean glucose level, hemoglobin A1c (HbA1c), total daily dose of insulin (TDDI), frequency of glucose monitoring and DSM responses were collected at baseline and 12 weeks.

RESULTS

The mean TIR was 59.8 ± 12.6%, TAR 32.7 ± 11.6%, TBR 7.5 ± 4.3%, mean glycemic variability, standard deviation 63.2 ± 12.5 mg/dL, and the coefficient of variation 41.3 ± 11.4% at 12 weeks. At baseline, the HbA1c level was 8.3%, and at 12 weeks, it dropped to 7.9% (p = 0.064). Baseline glucose monitoring frequency through BGM was 2.4/day; however, after the patients employed the FSL2, a higher degree of frequency of glucose monitoring was evident at 12 weeks as 8.2/day (p < 0.001). Significant improvements were observed in all the DSM subscales at 12 weeks.

CONCLUSION

Using FSL2 was found to raise the patients' DSM levels and improved metabolic control.

Experiences of Young People and Their Caregivers of Using Technology to Manage Type 1 Diabetes Mellitus: Systematic Literature Review and Narrative Synthesis

BACKGROUND

In the last decade, diabetes management has begun to transition to technology-based care, with young people being the focus of many technological advances. Yet, detailed insights into the experiences of young people and their caregivers of using technology to manage type 1 diabetes mellitus are lacking.

OBJECTIVE

The objective of our study was to describe the breadth of experiences and perspectives on diabetes technology use among children and adolescents with type 1 diabetes mellitus and their caregivers.

METHODS

This systematic literature review used integrated thematic analysis to guide a narrative synthesis of the included studies. We analyzed the perspectives and experiences of young people with type 1 diabetes mellitus and their caregivers reported in qualitative studies, quantitative descriptive studies, and studies with a mixed methods design.

RESULTS

Seventeen articles met the inclusion criteria, and they included studies on insulin pump, glucose sensors, and remote monitoring systems. The following eight themes were derived from the analysis: (1) expectations of the technology prior to use, (2) perceived impact on sleep and overnight experiences, (3) experiences with alarms, (4) impact on independence and relationships, (5) perceived usage impact on blood glucose control, (6) device design and features, (7) financial cost, and (8) user satisfaction. While many advantages of using diabetes technology were reported, several challenges for its use were also reported, such as cost, the size and visibility of devices, and the intrusiveness of alarms, which drew attention to the fact that the user had type 1 diabetes mellitus. Continued use of diabetes technology was underpinned by its benefits outweighing its challenges, especially among younger people.

CONCLUSIONS

Diabetes technologies have improved the quality of life of many young people with type 1 diabetes mellitus and their caregivers. Future design needs to consider the impact of these technologies on relationships between young people and their caregivers, and the impact of device features and characteristics such as size, ease of use, and cost.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Cutaneous adverse events in a randomized controlled trial of flash glucose monitoring among youth with type 1 diabetes mellitus

BACKGROUND

The literature regarding flash glucose monitoring (FGM)-associated cutaneous adverse events (AE) is limited.

OBJECTIVES

This study among youth participating in a 6 month randomized controlled trial aimed to compare cutaneous AE between FGM and self-monitored blood glucose (SMBG) use and evaluate premature FGM sensor loss.

METHODS

Patients aged 13 to 20 years with type 1 diabetes were randomized to intervention (FGM and usual care) or control (SMBG and usual care). Participants self-reported cutaneous AEs electronically every 14 days. Reports were analyzed to determine frequency, type, and severity of cutaneous AEs, and evaluate premature sensor loss.

RESULTS

Sixty-four participants were recruited; 33 randomized to FGM and 31 to control. In total, 80 cutaneous AEs were reported (40 in each group); however, the proportion of participants experiencing cutaneous AEs was greater in the FGM group compared to control (58% and 23% respectively, P = .004). FGM participants most frequently reported erythema (50% of AEs), while controls most commonly reported skin hardening (60% of AEs). For FGM users, 80.0% of cutaneous AEs were mild, 17.5% moderate, and 2.5% severe. Among controls, 82.5% of cutaneous AEs were mild and 17.5% moderate. One participant ceased using FGM due to recurring cutaneous AEs. Additionally, over 6 months, 82% of FGM participants experienced at least one premature sensor loss, largely unrelated to a cutaneous AE.

CONCLUSIONS

Cutaneous FGM-associated AEs are common, and mostly rated as mild. However, the majority of users continued FGM despite cutaneous AEs. Awareness of cutaneous complications and mitigation measures may reduce cutaneous AEs and improve the overall experience of FGM.

Intermittently scanned continuous glucose monitoring is associated with high satisfaction but increased HbA1c and weight in well-controlled youth with type 1 diabetes

OBJECTIVE

We undertook a 24-month prospective observational single-center real-world trial to study impact of access to intermittently scanned continuous glucose monitoring (isCGM) on quality of life (QOL) and glycemic control of youth with type 1 diabetes (T1D).

METHODS

Between September 2016 and November 2017, 138 children and adolescents with T1D were recruited. Demographic, metabolic, and QOL data were collected during 24 months of routine follow-up. Primary endpoint was the evolution of QOL, with secondary outcomes change in HbA1c, occurrence of acute diabetes complications, and school absenteeism.

RESULTS

Ninety-two percent of participants found isCGM more user-friendly than capillary finger-stick tests and had high treatment satisfaction, without change in diabetes-specific QOL. HbA1c significantly increased from 7.2% (7.0-7.3) (55 mmol/mol [53-56]) at baseline to 7.6% (7.4-7.8) (60 mmol/mol [57-62]) at 12 months (P < .0001) and was unchanged up to 24 months. Overall increase was mainly driven by children with baseline HbA1c <7.0% (<53 mmol/mol). Additionally, BMI adjusted for age was higher at study end. In year before isCGM, 228 days per 100 patient-years of school absenteeism were reported, which dramatically decreased to 13 days per 100 patient-years (P = .016) after 24 months. Parents of children also reported less work absenteeism (P = .011).

CONCLUSION

The use of isCGM by T1D pediatrics is associated with high treatment satisfaction and fewer days of school absence. However, increased HbA1c and weight may reflect a looser lifestyle, with less attention to diet and more avoidance of hypoglycemia. Intensive education specifically focusing on these points may mitigate these issues.

The 'flash' adhesive study: a randomized crossover trial using an additional adhesive patch to prolong freestyle libre sensor life among youth with type 1 diabetes mellitus

AIMS

Although strategies to prevent premature sensor loss for flash glucose monitoring (FGM) systems may have substantial benefit, limited data are available. This study among youth with high-risk type 1 diabetes evaluated whether an additional adhesive patch over FGM sensors would reduce premature sensor loss frequency and not cause additional cutaneous adverse events (AEs).

METHODS

This is a six-month, open-label, randomized crossover trial. Participants were recruited at completion of prior 'Managing Diabetes in a Flash' randomized controlled trial and allocated to three months of Freestyle Libre FGM sensors with either standard adhesive (control) or additional adhesive patches (RockaDex, New Zealand) (intervention), before crossing over to the opposite study arm. Participants self-reported patch use or non-use, premature sensor loss and cutaneous AEs fortnightly via an electronic questionnaire.

RESULTS

Thirty-four participants were enrolled: mean age (± SD) 17.0 (± 2.2) years; mean HbA1c (± SD) 89 (± 16) mmol/mol (10.3% ± 1.4%). The response rate of questionnaires was 77% (314/408). Premature sensor loss was reported in 18% (58/314) of questionnaires: 20% (32/162) from intervention and 17% (26/152) from control (p = 0.56). Thirty-eight percent (118/314) of questionnaires were non-compliant to protocol allocation. However, per-protocol analysis showed similar findings. No significant difference in AEs was reported between compliant adhesive patch use and non-use (6% [5/78] and 3% [3/118], respectively, p = 0.27).

CONCLUSIONS

The adhesive patch investigated in this study does not appear to prevent premature FGM sensor loss. However, the low risk of AEs and low cost of an adhesive patch suggest an individualized approach to their use may still be warranted. Further research is needed to explore alternative strategies to prevent sensor loss.

Effectiveness of the Freestyle Libre Flash Glucose Monitoring System on Diabetes Distress Among Individuals with Type 1 Diabetes: A Prospective Study

AIM

To study and explore the intervention of the flash glucose monitoring system (FGMS) on diabetes-related distress (DRD) in children and adolescents with type 1 diabetes (T1D).

METHODS

A 12-week prospective study was performed from March 2019 to July 2019 involving 187 children and adolescents (age range 13-19 years; 56.7% female) with T1D who were self-testing their glucose levels using the conventional fingerprick method. At the time of the baseline visit, FGMS sensors were fixed by a trained diabetes educator onto each patient in the study population. A trained interviewer also administered the 28-item T1-Diabetes Distress Scale (T1-DDS) questionnaire to each participant at the baseline visit and again after 12 weeks to determine the T1-DDS score.

RESULTS

Comparison of the baseline (fingerprick) data with data collected at 12 weeks after the patients had switched to the FGMS revealed a significant decrease in the subdomains of the T1-DDS as follows: powerlessness (p = 0.0001); management distress (p = 0.0001); hypoglycemia distress (p = 0.0001); negative social perceptions (p = 0.0001); eating (p = 0.0001); physician distress (p = 0.0001); friend/family distress (p = 0.0001); and total T1-DDS score (p = 0.0001). Similarly, analysis of the data revealed that there was also a substantial drop from baseline to 12 weeks after initiation of the intervention in the clinical variables assessed, such as glycosylated hemoglobin; specifically, there was a considerable decrease after 12 weeks in the frequency of hypoglycemia. Interestingly, the frequency of glucose monitoring also showed an upswing among users of the FGMS.

CONCLUSION

The outcomes of this study clearly demonstrate that once the patients had been switched from the fingerprick method to FGMS, the DRD and related clinical parameters showed remarkable improvement. However, further studies are necessary to determine whether the continued and consistent use of the FGMS will achieve better results.

Acceptability of the FreeStyle Libre Flash Glucose Monitoring System: The Experience of Young Patients With Type 1 Diabetes

Background:

In the current era of modern technology, the development of smart devices such as the flash glucose monitoring (FGM) systems helps patients with diabetes to effortlessly monitor their glucose levels more frequently. In this study, we determine the user acceptability of FGM among young patients with type 1 diabetes (T1D).

Methods:

A cross-sectional study was performed among 67 young patients with T1D in the age group of 13 to 19 years and who were managed on the FGM method for self-testing the glucose levels for a minimum of 6 months. The participants acceptability measures that were collected with a standard questionnaire and where they rated their experience with the system on a scale of 1 (strongly agree/painless) to 5 (strongly disagree/severe pain). In addition to the demographic and clinical parameters, a closed/structured questionnaire was administered, in order to record the prior and present skin issues, over a 6-month period.

Results:

From the patient statements regarding sensor application, 95.5% of the study population strongly agreed that the sensor application caused less pain than the routine finger-stick. Similarly, 85% of the users strongly agreed that using the sensor was comfortable, while 94% strongly agreed that they found the small size of the FGM made it easy to wear, 47.8% strongly agreed that wearing the sensor did not attract attention, 70.1% reported no discomfort under the skin, 80.6% stated that the sensor could be scanned without anyone noticing it, 89.6% felt that the sensor did not affect their daily activities, 91% strongly agreed that the sensor was very compatible with their lifestyle, 79.1% reported ease with taking a glucose reading with the scan, 89.6% reported that taking glucose readings with this system would not disrupt their daily activities, and 76.1% participants were excited to share with other individuals their experiences with this system. A comparison of the self-monitoring of blood glucose and freestyle techniques demonstrated that 83.6% participants strongly agreed that it was less painful to get glucose readings from the freestyle sensor, and that it was a more discreet (83.6%), more comfortable (85.1%), easier (95.5%), faster (82.1%), simpler (79.1%), more private (88.1%), and less stressful (77.6%) method, with minimal hassle (74.6%). It is notable here that 86.6% of the participants reported absolutely no pain when the freestyle sensor was applied; also, the majority of the participants (91%) reported no pain symptoms when scanning the sensor.

Conclusion:

The findings of this study clearly showed that the study population had a high level of acceptability of the FGM.

Cutaneous Complications With Continuous or Flash Glucose Monitoring Use: Systematic Review of Trials and Observational Studies

BACKGROUND

Continuous glucose monitoring (CGM)/flash glucose monitoring (FGM) use in diabetes management is increasing. Cutaneous complications associated with these devices were reported. We conducted a systematic review to provide an overview of cutaneous complications with CGM/FGM use.

METHODS

We identified observational studies and intervention trials that report on cutaneous complications with CGM/FGM use up to January 14, 2019. Studies were identified through Medline, Embase, and PubMed, or with hand searching of the previous publications. Screening was duplicated and data extracted to consider four main themes: incidence rate and severity, participant perspectives of cutaneous complications, potential solutions, and future directions in diabetic technology relevant to reducing cutaneous complications.

RESULTS

A total of 54 eligible studies were identified. The overall event rate of cutaneous complications reported from 19 trials was one event per eight weeks of sensor wear-time of which 1.5% were considered severe. The most common cutaneous complications were wear-related erythema, itching, and induration. Although skin irritations were the most common cause of CGM/FGM discontinuation, most users experienced less pain or discomfort with CGM/FGM than capillary blood glucose testing. Future technological advances may reduce, but not eliminate cutaneous complications.

CONCLUSION

The incidence rate of reported cutaneous complications with CGM/FGM use from the available literature is low, with one event per eight weeks of sensor wear-time. Reported complication severity was also low, leading to low rates of CGM/FGM discontinuation. However, there appear to be discrepancies between reporting in trial and observational data. Greater constancy in reporting is necessary to understand the frequency of this issue.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Initial experiences of adolescents and young adults with type 1 diabetes and high-risk glycemic control after starting flash glucose monitoring - a qualitative study

Purpose

This study explored early experiences with a flash glucose monitoring system among adolescents and young adults with type 1 diabetes and high-risk glycemic control.

Methods

Adolescents and young adults with high-risk glycemic control (HbA1c ≥ 75 mmol/mol (9.0%) in the previous 6 months) who had recently commenced on flash glucose monitoring as part of a trial took part in a semi-structured interview exploring their experiences with the technology. All interviews were recorded, transcribed and analyzed using an inductive approach.

Results

Fifteen interviews were conducted. Overall, participants enjoyed flash glucose monitoring and planned to continue using their system. Key findings included flash glucose monitoring reduced diabetes management burden and increased glucose monitoring. Other impacts of flash glucose monitoring use included perceived improved mood and energy, increased capacity for physical activity and less parental conflict. While participants reported healthier glycemic control, participants' mean interstitial glucose level remained above the target range of 3.9-10.0 mmol/L (70-180 mg/dL) over the first month of flash glucose monitoring. Common challenges included premature sensor loss and decreased scanning over the first month of use.

Conclusions

Flash glucose monitoring may be an acceptable self-management tool to increase monitoring frequency in adolescents and young adults with type 1 diabetes and high-risk glycemic control, with the potential to improve long-term glycemic control. Initial support efforts should focus on practical strategies to prolong sensor wear and motivate frequent scanning as well as education on interpreting glucose data and making informed treatment decisions to maximize the benefits of this technology.

Documentation of Skin-Related Issues Associated with Continuous Glucose Monitoring Use in the Scientific Literature

Background: The average wear time of continuous glucose monitoring (CGM) systems steadily increased over the last years. Increased wear times are likely achieved by using adhesives with a longer adherence time, which may have a more pronounced effect on the skin than adhesives with shorter adherence time. Methods: In this project, a structured literature search was performed to assess how potential skin-related issues with CGM usage have been reported in scientific literature in the last 5 years. The literature search was performed with four search terms in the PubMed database. Results: In sum, 279 articles were analyzed. Skin-related issues were mentioned in 19.0% of articles (53 out of 279). With respect to articles mentioning skin-related issues, CGM performance or efficacy was the study's main topic of most of these studies, whereas the minority used CGM as "add-on" to assess other objectives. There was a varying degree in how detailed skin-related issues were described and no uniform structured documentation was given. While some articles only described findings, other articles already documented final diagnoses, such as contact dermatitis. Furthermore, inconsistent wordings for comparable issues were used. The most frequent issues were pain, itching, erythema, bleeding, bruising, and allergic reactions. Conclusion: To draw possible conclusions about the occurrence of skin-related issues during CGM use, more reports about skin-related issues in scientific literature are needed. A more detailed and uniformly structured documentation, possibly facilitated by a generally accepted guideline for structured descriptions, of skin-related issues could be helpful to enable clear differentiations between the described skin reactions.

Differences of FreeStyle Libre Flash Glucose Monitoring System and Finger Pricks on Clinical Characteristics and Glucose Monitoring Satisfactions in Type 1 Diabetes Using Insulin Pump

Background:

To evaluate the different experience of freestyle libre and finger pricks on clinical characteristics and glucose monitoring satisfaction (GMS) in patients with type 1 diabetes (T1D) using insulin pump (IP).

Methods:

A prospective study was carried out on 47 (aged 17-21 years) T1D, who used conventional finger-pricking method for self-testing the glucose. The experiments were conducted between March 2018 and September 2018. For carrying out the study, the flash glucose monitoring (FGM) sensors were placed on each participant, at the baseline visit, by a trained diabetes educator. Furthermore, to determine the total number of scans conducted during the study period, the respective ambulatory glucose profiles were generated by computing the data collected from the sensors. In addition, a trained interviewer handed over the GMS questionnaire to each patient, at the baseline and at 12 weeks of the study.

Results:

In comparison to the baseline (finger pricks), various parameters such as: HbA1c (P = .042), hypoglycemia (P = .001), mean capillary glucose (P = .004), total daily insulin dose (P = .0001), percentage of bolus insulin (P = .0001), daily bolus frequency (P = .0001), and daily carbohydrates intake (P = .0001) showed a significant improvement at 12 weeks. Similarly, substantial augmentation was noticed, in the sub domains of GMS, that is, openness (P = .0001), emotional burden (P = .0001), behavioral burden (P = .0001), and trust (P = .0001) at 12 weeks as compared to baseline. Overall, total GMS score at baseline was 1.72 ± 0.37, which increased up to 3.41 ± 0.49 (P = .0001) in the time period of 12 weeks. The HbA1c (r² = 0.45), hypoglycemia (r² = 0.58), and the mean number of FGM scans, exhibited a negative correlation, while GMS (r² = 0.52) and the mean number of FGM scans, exhibited a positive correlation.

Conclusion:

The frequency of hypoglycemia, HbA1c level, capillary glucose, daily carbohydrates intake decreased, while the total daily insulin dose, daily bolus insulin and total GMS score increased with the use of FGM scanning for 12 weeks.

Flash Glucose Monitoring Accepted in Daily Life of Children and Adolescents with Type 1 Diabetes and Reduction of Severe Hypoglycemia in Real-Life Use

Background: Flash glucose monitoring (FGM) is covered by the Belgian public health insurance for type 1 diabetes since 2016. The objective of this study was to describe the use of FGM and diabetes outcomes in type 1 diabetic children and adolescents 1 year after reimbursement. Methods: All patients had the choice to convert to FGM or to continue with self-monitoring of blood glucose (SMBG). Clinical data were collected at baseline, at the next visit, and after 12 months; glucose profiles at next visit and after 12 months. Regression analyses were performed to identify predictors of FGM acceptance and changes in metabolic control. Results: A total of 334 subjects were included, of whom 278 (83.2%) switched to FGM. They were younger (13.6 vs. 15.2 years; P = 0.012) and performed more SMBG testing at baseline than patients who did not switch (4.3 vs. 4.1 tests daily; P = 0.008). At the end of follow-up, the rate of severe hypoglycemia decreased by 53% in the group of FGM users (P = 0.012) while it remained stable in SMBG users. Median glycated hemoglobin did not change significantly in both groups. Among subjects who switched to FGM, 15.8% reverted to SMBG after a median use of 5.3 months. Adverse events, diabetes duration, and FGM utilization were independent predictors of the risk for reverting. FGM-related adverse events were associated with a fivefold increased risk to revert to SMBG (hazard ratio = 5.12; P < 0.0001). Conclusions: FGM is relatively well accepted and decreases the risk of severe hypoglycemic events in our pediatric population. FGM is more often discontinued in patients experiencing adverse events and with longer diabetes duration.